FirstCare LCOC Health Plan D 2M Summary

Health Plan D 2M
Covered Services		Member Responsibility
Lifetime Maximum		$2,000,000
Limited Inpatient Services No deductible, Mental Illness Limitiations	Tier 1 Hospital contracted, within the Service Area	$200 per day per admission $1,000 max per admission
	Tier 2 Hospital contracted, outside the Service Area	30% of the allowable amount

Limited Doctor Office Visits No deductible	Primary Care Physician Limited to three visits per member per contract year	$25 per visit

Contract Year Deductible - All Other Services		$15,000 per member

Emergency Care Services	Emergency Room	$100 per visit after deductible Waivedif admitted to hospital
	Urgent Care or Minor Emergency	$55 per visit
	Ambulance	$150 per trip after deductible
For more detailed information visit the plan documents: Benefit Summary Prescription Drug Benefit

For more detailed information visit the plan documents: